Citation NR: 9614268
Decision Date: 05/23/96 Archive Date: 06/04/96
DOCKET NO. 94-36 472 ) DATE
)
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On appeal from the
Department of Veterans Affairs Regional Office in Montgomery,
Alabama
THE ISSUES
1. Entitlement to service connection for a low back
disorder, claimed as ruptured disc.
2. Entitlement to service connection for heart disease,
manifested by angina.
3. Entitlement to service connection for prostatitis.
REPRESENTATION
Appellant represented by: Alabama Department of Veterans
Affairs
ATTORNEY FOR THE BOARD
J. Fussell, Counsel
INTRODUCTION
The veteran had active service from November 1962 until
October 1992.
This matter initially comes before the Board of Veterans'
Appeal (Board) from a July 1993 rating action of the
Department of Veterans Affairs (VA) Regional Office (RO) in
Montgomery, Alabama.
The issue of service connection for heart disease is dealt
with in the remand portion of the decision.
CONTENTIONS OF APPELLANT ON APPEAL
The veteran contends that low back disability and prostatitis
were present during service.
DECISION OF THE BOARD
The Board, in accordance with the provisions of 38 U.S.C.A.
§ 7104 (West 1991 & Supp. 1995), has reviewed and considered
all of the evidence and material of record in the veteran's
claims file(s). Based on its review of the relevant evidence
in this matter, and for the following reasons and bases, it
is the decision of the Board that the preponderance of the
evidence supports the claim for service connection for
history of ruptured disc and arthritis of the lumbar spine;
and that the preponderance of the evidence is against the
claim for service connection for prostatitis.
FINDINGS OF FACT
1. Service medical records reflect low back pain identified
as mqanifestation of possible ruptured disk L4-5 degenerative
arthritis in the spine.
2. Service medical records reflect treatment for episodes of
prostatitis.
3. The prostatitis for which the veteran was treated in
service was acute and transitory and resolved with treatment
without residual disability.
CONCLUSIONS OF LAW
1. Chronic low back disability, history of ruptured disk L4-
5 degenerative arthritis of the spine, was incurred in
service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 1991).
2. The veteran does not have chronic prostatitis which was
incurred in or aggravated by service. 38 U.S.C.A. §§ 1110,
1131, 5107 (West 1991).
REASONS AND BASES FOR FINDINGS AND CONCLUSION
VA shall grant service connection for disability resulting
from personal injury suffered or disease contracted in
service. 38 U.S.C.A. §§ 1110. 1131.
The veteran's service medical records reflect that on
orthopedic evaluation in 1977, his back problems were best
described as possible ruptured disc in the lower lumbar
spine. On examination in 1982, it was noted that he had had
a ruptured L4 disc in November 1976 with no problems after 8
months. On the retirement examination in August 1992, the
examiner noted ruptured disk L4-5 degenerative arthritis in
the spine. When he underwent VA examination in January 1993,
findings with respect to the low back included tenderness and
pain at the extremes of motion. X-rays showed hypertrophic
changes.
Although the examiner who conducted the January 1993 VA
examination failed to include a diagnosis of chronic low back
disability, the VA radiologist's report confirms that the
veteran has arthritis of the low back. There is also a
history of ruptured disk reflected in his service medical
records. The Board is of the opinion that the preponderance
of the evidence shows that the veteran has chronic low back
disability, characterized as history of ruptured disc and
arthritis, which had its onset in service. Accordingly,
service connection for the history of ruptured disc with
arthritis of the low back is warranted.
With respect to the prostatitis claim, the veteran's service
medical records reflect that he was treated for prostatitis
on two occasions in the late 1980's. However, when he was
examined in June 1990 (the "over 40" examination) and in
August 1992 for separation from service there were no
findings of prostate disability. Further, when he underwent
VA examination in January 1993, he complained only of history
of prostatitis, and the examiner concluded: [h]istory of
intermittent prostatitis, treated, no acute complaints at
present." In his statements and forms submitted in
connection with the current claim, he has not referred to
post-service prostatitis.
38 C.F.R. § 3.303(b) provides that when the fact of
chronicity in service is not adequately supported, then a
showing of continuity after discharge is required to support
the claim. In this case, the record shows that the veteran
was treated for two episodes of prostatitis in service.
These episodes were not described by treating personnel as
manifestations of chronic disability, and, following
treatment for the second episode, the medical record reflects
no further references to prostatitis and shows no residuals
of the in-service prostatitis. The Board concludes that the
in-service episodes of prostatitis were acute and transitory
and resolved with treatment without residual disability.
Inasmuch as the evidence shows neither chronic prostatitis
nor residuals of prostatitis, there is nothing to service
connect, and the claim is denied.
ORDER
Service connection for chronic low back disability, history
of ruptured disk with arthritis, is granted.
Service connection for prostatitis is denied.
REMAND
With respect to the claim for heart disease, the service
medical records reflect that the veteran reported chest pain
and pressure, but the heart was normal when he was examined
for separation from service. When he underwent VA
examination in 1993, he reported a history of angina.
Findings included regular rate and rhythm of the heart with
no gallops, murmurs or rubs. A chest X-ray was negative.
Nevertheless, the diagnosis, apparently based on the
veteran's history, was "[c]oronary artery disease with
history of anginal-like pain, no cardiac catheterization."
The chest pain reportedly was produced by anxiety or stress.
The Board requires additional medical evidence as to whether
the veteran has heart disease, and, if so, whether it began
in service or is related to service connected diabetes
mellitus.
According, the case is remanded for the following:
1. The RO should ask the veteran if he has
received post-service treatment for heart disease.
All such records should be obtained and associated
with the claims file.
2. The veteran should be afforded a VA
cardiovascular examination to determine whether he
now has cardiovascular disease. Following the
examination, the examiner should answer the
following questions: If the veteran has heart
disease, (1) was if first manifested in service or
within one year of service; and (2) was it caused
by or related to service connected diabetes
mellitus? All indicated tests and studies should
be conducted. The claims folder must be made
available for review prior to the examination to
facilitate study of the case.
Thereafter, if the claims remain denied, the veteran and the
veteran's representative should be furnished a supplemental
statement of the case. They should be afforded the
appropriate period of time within which to respond thereto,
at their option, as provided by governing regulation. Then,
if otherwise in order, the case should be returned to the
Board after compliance with all requisite appellate
procedures.
NANCY I. PHILLIPS
Member, Board of Veterans' Appeals
The Board of Veterans' Appeals Administrative Procedures
Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, 741
(1994), permits a proceeding instituted before the Board to
be assigned to an individual member of the Board for a
determination. This proceeding has been assigned to an
individual member of the Board.
NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West
Supp. 1995), a decision of the Board of Veterans' Appeals
granting less than the complete benefit, or benefits, sought
on appeal is appealable to the United States Court of
Veterans Appeals within 120 days from the date of mailing of
notice of the decision, provided that a Notice of
Disagreement concerning an issue which was before the Board
was filed with the agency of original jurisdiction on or
after November 18, 1988. Veterans' Judicial Review Act, Pub.
L. No. 100-687, § 402 (1988). The date that appears on the
face of this decision constitutes the date of mailing and the
copy of this decision that you have received is your notice
of the action taken on your appeal by the Board of Veterans'
Appeals. Appellate rights do not attach to those issues
addressed in the remand portion of the Board's decision,
because a remand is in the nature of a preliminary order and
does not constitute a decision of the Board on the merits of
your appeal. 38 C.F.R. § 20.1100(b) (1994).
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